Provider Demographics
NPI:1821613985
Name:MILLER, MATTHEW GREGORY (STUDENT - SRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GREGORY
Last Name:MILLER
Suffix:
Gender:M
Credentials:STUDENT - SRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3835 NW 22ND TER
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33993-3511
Mailing Address - Country:US
Mailing Address - Phone:901-496-3201
Mailing Address - Fax:
Practice Address - Street 1:350 7TH ST N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5754
Practice Address - Country:US
Practice Address - Phone:239-624-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-14
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11010869367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered